Maximizing Your Insurance Coverage

by Susan H. Loeb, JD

Part of successfully coping with
cancer includes having control
over your medical bills and insurance.
It’s not easy for anyone, let
alone someone undergoing cancer
treatment. To maximize your health
benefits, you need to know how to
navigate the system, safeguard your
existing coverage, and understand
what is available if you have insufficient
coverage or no coverage at all.

Understanding Your Coverage
If your insurance plan is a preferred
provider organization, or PPO, you
should know your deductible, co-insurance,
co-payments, and annual
out-of-pocket limit. Use in-network
providers, if possible, to avoid large
bills. Be sure to ask your specialist if
he or she is part of the PPO network
because out-of-network doctors often
work within in-network treatment centers.
If you go to an out-of-network
provider, you are responsible for paying
the amount over the PPO approved
amount. This amount will not count
towards your out-of-pocket limit.

With health maintenance organization,
or HMO, coverage, your primary
care doctor controls your access to
specialists. Make sure that you obtain
a referral before treatment starts because
without the referral, the HMO
won’t pay. If you wish to receive
treatment from non-HMO doctors, you
will have to demonstrate that the outof-
network treatment is superior to
and not available through the HMO.
You will need to get your primary care
physician and managed care doctors
to support you in this request.

Understanding the Insurance
Process When you receive medical
services, the provider submits a claim
to the insurer with industry-standard
billing codes for treatment and diagnoses.
The codes drive the entire
determination of coverage and benefits.
When the claim is processed, an
Explanation of Benefits is generated,
listing the provider, the date of service,
the total charge, the approved amount,
the amount paid, and the amount you
may be billed. Keep EOBs in chronological
order by date of service. When
you receive a bill, compare it against
the EOB, and don’t pay it until you are
satisfied that it is correct. Never pay a
provider until you have seen an EOB.

You need to know how to navigate the system.

Claim Problems and Denials
Insurers can incorrectly pay for or flatly
deny coverage for a variety of reasons.
Claim denials due to clerical coding
errors are very common and are the
easiest to fix if you are willing to spend
the time needed to correct them. Contact
the insurer if you suspect that your
claim was denied because of an incorrect
diagnosis or service code. Ask for
the reason for the denial, and request
the procedure code(s) and/or diagnosis
used. If the provider erred, ask them
to resubmit the claim with the correct
information. Insurers will not reprocess
such errors on their own.

If an insurer determines that a service
is not “medically necessary,” it will
deny the claim, especially in the precertification
process. To get coverage,
your doctor will need to submit additional
medical information to show
“medical necessity.” If the insurer still
refuses to pre-certify, follow the formal
appeal process set forth in your
plan or policy.

The scariest denial is when the
insurer determines that the service
is not covered by your plan or policy.
A common exclusion invoked in cancer
treatment is services deemed as
“experimental treatment.” To overturn
such a denial, you must follow the appeals
process and procedures. You
cannot circumvent this time-consuming
and sometimes lengthy process.
But if you stick with it, you may very
well prevail. In preparing an appeal,
follow these steps:

Ask doctors to join in the appeal.

Notify your provider that you are
appealing so your claim is not placed
in collection.

Ask questions until you understand
fully the factual basis for the denial.

Take copious notes, including the
name of the person you spoke with,
the date, and the time. Careful notes
can prove invaluable.

Remain cordial; be professional.

Keep the appeal concise and directed,
but complete. If you ultimately
resort to litigation, the court’s role
may be limited to
whether the denial
was arbitrary and
capricious.

Enlist the support
of your employer,
if appropriate.

Don’t give up.
Insurers don’t
make it easy, but many denials
are overturned.

♦ ♦ ♦ ♦ ♦

Susan Loeb is an attorney
and founder of Your Benefits Advocate.
YBA provides advocacy, consulting, and
administrative services to individuals
seeking help in solving problems with their health and disability benefits.

Navigating the system on your own can be overwhelmingly difficult. For help, contact your state's Department of Insurance, support organization such as the Patient Advocate Foundation, the Alliance of Claims Assistance Professionals, or a private attorney.

This article was originally published in Coping® with Cancer magazine,
November/December
2007.